Refer a Patient

Referral date:

Patient name & DOB:

Patient contact details:

Referred by:

Radiographs enclosed?YesNo
Maximum file size for each attachment is 4Mb. If the file you want to attach is too large, please email it to us instead on [email protected]
Reason for referral:Consultation/2nd OpinionManagement of periodontal diseaseImplant placementManagement of mucogingival problemCrown lengtheningSoft/hard tissue augmentationSinus augmentationExposure of unerupted toothManagement of peri-implant diseaseOther (please specify)

Would you like to be involved in periodontal maintenance of your patient?YesNo

Will you restore the implant?YesNo

Notes:

About Precision Periodontics

Dr Ehsan Mellati obtained his specialty training from the prestigious periodontic training program at Melbourne University.

Dr Ehsan Mellati provides a range of services to manage and treat gum disease, as well as providing specialised dental implant services.